San Francisco Chronicle - Wednesday, May 13, 2009

He's drawing howls for both his domestic and overseas AIDS policies. AIDS groups badly want to expand Bush-era policies they favored while doing away with conservative policies they opposed, such as a ban on federal money for needle exchanges. For these critics, Obama isn't moving fast or far enough.

It's an unfair rap for the most part. But the problem underscores the loaded expectations that Obama brought with him to the White House. The Obama brain trust, hemmed in by a huge financial deficit and political caution, clearly wants to go slow.

On the international level, the new president is proposing $51 billion in AIDS spending over the next six years. But the year-by-year increases during this period, it turns out, are less than the $1 billion allotments he promised on the campaign trail. The boost for next year, for example, will be by $366 million , not the promised $1 billion .

Also, he's adding a further $12 billion to include several preventable tropical diseases that harm children. Where did that idea come from? A health policy expert, Dr. Ezekiel Emanuel , who happens to be the brother of Obama's chief of staff, Rahm Emanuel.

None of this should disappoint or infuriate AIDS activists, though it has. Their gripe is that the existing U.S. program is showing results in stemming infections and Obama shouldn't go back on an important promise to expand that success. Also, widening the fight by adding other targeted diseases shouldn't come at the expense of battling the virus that causes AIDS, critics say.

There are other worries. The White House isn't following through on a promise to allow federal money for needle exchanges, a proven winner in curbing infections though a tough political sell. It's a contorted position: Several key Obama health appointees favor needle swaps though White House budget language continues the ban.

In addition, as the economy weakens and stimulus bills pile up, there are worries that foreign aid such as the giant AIDS program will feel the ax. An added reality check: this week's rising tide of federal red ink, with a predicted $1.8 trillion deficit.

These doubts are worth noting. But they shouldn't obscure the bigger picture. The AIDS fight remains a signature American initiative, and the White House is hardly walking away from a commitment no other nation has taken on with such scale.

The program's record in tamping down infection rates and building public health systems is all the more remarkable as the world struggles to coordinate a defense against swine flu. Adding on funds to go after other tropical diseases, diarrheal infections and infant pneumonia - all treatable - makes solid health-policy sense. Obama's headed in the right direction, ever so cautiously.
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